Search

The sigmoid colon simulator was designed to accurately reproduce the anatomical layer structure and the arrangement of characteristic organs in each layer, and to have conductivity so that energy devices can be used. Dry polyester fibers were used to reproduce the layered structures, which included characteristic blood vessels, nerve sheaths, and intestinal tracts. The adhesive strength of the layers was controlled to allow realistic peeling techniques. The features of the Sigmaster are illustrated through a comparison of simulated sigmoidectomy using Sigmaster and actual surgery. We developed a laparoscopic sigmoidectomy simulator called Sigmaster. Sigmaster is a training device that closely reproduces the membrane structures of the human body and allows surgeons to experience the entire laparoscopic sigmoidectomy process., (© 2024. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Purpose: To investigate the association between perioperative deglutition screening and postoperative respiratory complications (PRCs) in elderly patients undergoing gastrectomy for gastric cancer., Methods: We analyzed data from 86 patients with gastric cancer (aged ≥ 70 years) who underwent gastrectomy between October, 2016 and November, 2018. Videofluoroscopic swallowing examinations (VFSEs) were performed before and after surgery. We examined the association of these results with postoperative respiratory complications, as well as the relationships between demographic, operative, and swallowing function assessment data., Results: PRCs were identified in 16 patients. The results of pre- and postoperative VFSE showed abnormalities in 28 and 32 patients, respectively. Multivariate analysis revealed that abnormalities in the postoperative VFSEs were strongly associated with the development of PRCs (P = 0.002). The findings of this analysis suggests that ventilatory impairment, a Charlson comorbidity index score ≥ 3, and an open surgical approach are independent risk factors for PRCs., Conclusion: This is the first study to demonstrate the efficacy of perioperative assessment of swallowing function using VFSE for predicting PRCs in elderly patients undergoing gastrectomy for gastric cancer., (© 2023. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Purpose: In abdominoperineal excision (APE), the advantages of the "down-to-up" approach are expected to be more obvious when performed as a two-team approach, including transperineal minimally invasive surgery (TpMIS). We investigated the efficacy of TpMIS with laparoscopic APE for lower rectal cancer., Methods: Patients who underwent laparoscopic APE with (n = 20) or without (n = 30) TpMIS between December 2013 and April 2020 were retrospectively reviewed. Patient and tumor characteristics, intraoperative outcome, short-term outcome, and pathological findings were compared. Additional subgroup analyses were performed in technically challenging cases, including male patients, obese patients, and patients with tumors located at the anterior wall., Results: There was no marked difference in the patient or tumor characteristics or short-term outcomes, including morbidity and mortality between the two groups. Pathological results were comparable, and the circumferential resection margin (CRM) positive rate was 10% in both groups. TpMIS achieved a significant reduction in operative time (p = 0.02). In a subgroup analysis, the amount of blood loss was also smaller in males (p = 0.02) and patients with a high BMI (> 25) (p = 0.005) than in others., Conclusion: Simultaneously performing TpMIS and laparoscopic APE is feasible owing to the favorable complication and CRM-positive rates. In terms of operative time and blood loss, TpMIS is expected to be advantageous in both easy and challenging cases., (© 2022. The Author(s) under exclusive licence to Springer Nature Singapore Pte Ltd.)

Purpose: Rectal gastrointestinal stromal tumors (GISTs) surgery is often challenging owing to the anatomical constraints of the narrow pelvis and tumor hugeness. Despite the increasing number of patients undergoing trans-anal total mesorectal excision (taTME) globally, the feasibility of trans-anal surgery with the taTME technique for rectal GISTs remains unclear. We aimed to evaluate the feasibility of trans-anal surgery with the taTME technique for rectal GISTs., Methods: Using a prospectively collected database, we retrospectively analyzed the clinical findings, surgical outcomes, pathological outcomes, urinary and anal functions, and prognoses of patients who underwent trans-anal surgery with the taTME technique for primary rectal GISTs at the National Cancer Center Hospital East from September 2014 to March 2020., Results: Twenty-one patients with primary rectal GISTs were included in this study. The median distance from the anal verge to the lower edge of the tumor was 40 mm (range, 15-60 mm), and the median tumor size was 59 mm (range, 11-175 mm). Moreover, seven and 14 patients underwent one-team and two-team surgeries, respectively, with curative intent. Nineteen patients (90.5%) underwent anus-preserving surgery, and the urinary tracts were preserved in all cases. Two-team surgery showed a significantly lower blood loss volume and shorter operation time than one-team surgery (58 vs. 222 mL, P = 0.017; 184 vs 356 min, P = 0.041, respectively). The pathological negative-margin resection rate was 100%. During the follow-up period, no patient developed local GIST recurrence and one (4.8%) developed distant metastasis., Conclusion: Trans-anal surgery with the taTME technique is feasible for rectal GISTs, and two-team surgery may be more advantageous than one-team surgery in terms of operation time and blood loss., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: Severe defecation disorder occurs frequently in coloanal anastomosis for low rectal cancer, and may affect quality of life. Sacral neuromodulation (SNM) has been reported to be successful after rectal resection, but there are no results for patients treated with intersphincteric resection (ISR)., Methods: A retrospective single-center study of SNM was performed for patient with defecation disorder following ISR. Pre- and post-treatment bowel frequencies, fecal incontinence episodes, and Wexner, LARS and FIQL scores were assessed to evaluate the efficacy. A good response was defined as ≥ 50% reduction of bowel frequency per day or fecal incontinence episodes per week., Results: 10 patients (7 males, mean age 67.5 years) underwent SNM. All patients had severe fecal incontinence with a median Wexner score of 15 (13-20) and a median LARS score of 41 (36-41). The Wexner score improved after SNM, but not significantly (p = 0.06). LARS and FIQL scores significantly improved after SNM (p = 0.02, p = 0.01). At the end of follow-up, the good response rate was 40%. Three cases without a good response required creation of a permanent stoma., Conclusion: Seven out of 10 patients did not require a permanent colostomy after SNM. SNM should be considered before performing a permanent colostomy., (© 2021. Springer Nature Singapore Pte Ltd.)

Purpose: Mucosal prolapse at the site of anastomosis is a long-term complication unique to ISR. It reduces the QOL of patients due to a worsened anal function and local symptoms around the anus. We herein sought to assess the surgical outcomes after Delorme surgery for these patients., Methods: ISR was performed in 720 patients with low rectal cancer between January 2001 and March 2019 at the National Cancer Center Hospital East. Among these patients, the 33 (4.5%) who underwent initial Delorme surgery for postoperative colonic mucosal prolapse were identified from the medical records and then were analyzed retrospectively. We estimated the anal function using Wexner's incontinence score and assessed whether local anal symptoms due to the prolapse improved postoperatively., Results: Stoma closure was performed before Delorme surgery in 15 (45.5%) patients, and we compared the preoperative and postoperative anal function in these patients. The average Wexner's incontinence score changed from 15.1 before to 12.9 after Delorme surgery. Local symptoms around the anus improved in all 33 (100%) patients. Recurrence of colonic mucosal prolapse occurred in 5 patients (15%), and Delorme surgery was reperformed in these cases., Conclusion: Delorme surgery for colonic mucosal prolapse following ISR has clinical benefits for both improving anal local symptoms and slightly improving the anal function.

Purpose: The relevance of transvaginal specimen extraction (TVSE) combined with reduced port surgery (RPS) remains unknown. This study investigated the feasibility of TVSE with RPS according to short-term outcomes and cosmesis., Methods: This prospective multicenter study enrolled ten patients at three institutions. For the semi-quantification of each parameter, we administered questionnaires to assess pain (visual analogue scale), subjective/objective wound healing esthetics [photo series questionnaires (PSQ)], and quality of life (QOL)., Results: No operative complications occurred, except one case of urinary tract infection, which was promptly cured with antibiotics. On day 0, pain was rated at 2.3 ± 0.67 at rest and 4.9 ± 0.82 during sneezing; these ratings gradually declined over time. The PSQ showed that the patient ratings of wound esthetics after TVSE were not inferior to ratings from patients after conventional laparoscopy or single incision laparoscopic surgery, and they were significantly higher than the patient ratings of wounds after laparotomy (P < 0.05). The QOL scores showed that, in comparison to before surgery, after surgery, patients reported significant deterioration of their physical function (96.67 ± 1.49 vs. 87.33 ± 2.71), emotional function (93.33 ± 2.72 vs. 86.67 ± 2.22), fatigue (7.78 ± 3.72 vs. 26.67 ± 8.31), and pain (6.67 ± 3.69 vs. 18.33 ± 4.61)., Conclusion: TVSE with RPS for colorectal cancer was feasible and was associated with a low degree of postoperative pain.

Purpose: Whether indocyanine green fluorescence angiography (ICG-FA) during rectal surgery is effective in reducing anastomotic leakage remains unclear. This study aimed to investigate the effect of intraoperative ICG-FA on anastomotic leakage after sphincter-sparing surgery for malignant rectal tumors., Methods: This was a retrospective, single-center cohort study conducted on 852 consecutive patients who underwent laparoscopic sphincter-sparing surgery from January 2007 to June 2017 at our institution. The incidence of anastomotic leakage was compared between patients who underwent ICG-FA to determine the proximal resection margin and those in whom this technique was not performed, using logistic regression analysis, including propensity score., Results: A total of eight patients were excluded (one patient with previous low anterior resection and seven patients who underwent simultaneous resection for other primary cancers), resulting in 844 patients being analyzed. Before propensity score matching, 141 patients (16.7%) who underwent ICG-FA were compared with 703 patients (83.3%) in whom ICG-FA was not performed. The incidence of anastomotic leakage was 2.8% (4/141) in the ICG-FA group and 12.4% (87/703) in the control group (p = 0.001). After propensity score matching (n = 420), the patient characteristics between the two groups were well balanced, and the incidence of anastomotic leakage was 2.8% (4/141) in the ICG-FA group and 13.6% (38/279) in the control group (p = 0.001). Logistic regression analyses using propensity score showed that patients who underwent ICG-FA had significantly lower odds of anastomotic leakage., Conclusion: Intraoperative ICG-FA is a promising method to reduce anastomotic leakage after laparoscopic rectal surgery.

Purpose: Peristomal skin disorders (PSDs) are common stoma-related complications. However, there is no standard method for the evaluation of PSDs, and the true incidence is unclear. There are also no reports on risk factors for severe PSDs. Therefore, this study was performed to analyze the incidence of PSD in temporary loop stoma based on the DET score and ABCD-stoma score and to determine the risk factors for all and severe PSDs., Methods: A retrospective analysis of patient and surgical characteristics was carried out in 333 consecutive cases of stoma creation with loop ileostomy or colostomy performed at our hospital from January 2014 to December 2016., Results: PSDs were diagnosed in 262 patients (78.7%), including 79 (23.7%) and 71 (21.3%) that were defined as severe based on DET and ABCD-stoma scores, respectively. Multivariate analyses showed that parastomal hernia was an independent risk factor for severe PSD defined by DET score and that adjuvant chemotherapy was an independent risk factor for severe PSD defined by the ABCD-stoma score., Conclusions: Severe PSDs are associated with parastomal hernia when diagnosed by the DET score and with adjuvant chemotherapy when diagnosed by the ABCD-stoma score.

Purpose: We developed the "Foot-Site Monitor" (FSM) to permit easy identification of multiple foot pedals of energy devices in endoscopic surgery. The purpose of this study was to evaluate the effectiveness of the use of the FSM., Methods: Using a training box, 20 surgeons performed a task consisting of pressing foot pedals with and without the FSM. The time from showing a color on a PC monitor to pressing the foot pedal that corresponded to this color (defined as the completion time), and the distance of the movement of the tip of the surgeon's forceps from the beginning to the end of the task (defined as shaking of the forceps) were measured., Results: The use of the FSM was associated with significantly reduced shaking of the forceps (1.95 vs. 2.47 mm; p = 0.014), and a tendency toward a shorter completion time (1.39 vs. 1.51 s; p = 0.053)., Conclusions: The use of the FSM in endoscopic surgery contributes to reduced shaking of the forceps and may shorten the operative time.

Purpose: Postoperative urinary retention is a common adverse effect after rectal surgery. Current methods for assessing postoperative urinary retention (residual urine volume) are inaccurate and unable to predict long-term retention. Voiding efficiency is an effective indicator of postoperative urinary retention in urological and gynaecological fields, but not in colorectal surgery. We aimed to determine whether voiding efficiency in the initial 24 h after urinary catheter removal was more effective in predicting the incidence of postoperative urinary retention than residual urine volume., Methods: In this retrospective, observational study using prospectively collected data from patients who visited the colorectal department of a single institution, 549 patients who underwent rectal cancer surgery between April 2012 and May 2016 were initially enrolled, of which 46 were excluded and 503 finally included., Results: The incidence of postoperative urinary retention was 18.5% (93/503). Multivariable logistic regression analyses revealed that the association of postoperative urinary retention with voiding efficiency < 50% was stronger than that with residual urine volume > 100 mL (odds ratio, 38.30 (residual urine volume) and 138.0 (voiding efficiency)). Voiding efficiency was significantly lower in patients with long-term than in those with short-term postoperative urinary retention (adjusted p value = 0.02), whereas residual urine volume was not different between the two groups. Multivariable logistic regression analysis for long-term postoperative urinary retention showed the strongest association with voiding efficiency < 20% (odds ratio, 25.70)., Conclusions: Voiding efficiency is a more effective predictor of postoperative urinary retention than residual urine volume in rectal cancer patients.

Background: Few reports have evaluated the long-term outcomes of pathological T1 (pT1) lower rectal cancer (LRC), perhaps because pT1 LRC is classified as TNM stage I if lymph node metastasis (LNM) is absent and stage IIIA if LNM is present. Moreover, it is difficult to diagnose regional LNM preoperatively. This study aimed to clarify the long-term outcomes of radical surgery for pT1 LRC and risk factor(s) for LNM. Additionally, we examined whether preoperative computed tomography (CT) and magnetic resonance imaging (MRI) findings were predictive of LNM in pT1 LRC., Methods: This was a retrospective analysis of the clinical characteristics, short-term operative outcomes, and long-term survival rates of 155 patients who received radical surgery and were diagnosed with pT1 LRC at our hospital between January 1993 and February 2017., Results: Among patients with pT1 LRC, 5-year recurrence-free and overall survival rates were 94.0% and 95.8%, respectively. LNM status was not associated with statistically significant differences in recurrence-free or overall survival. Even in patients with LNM, the recurrence rate was only 9%. Among patients who lacked visible mesorectal lymph nodes on preoperative CT and MRI, LNM rates were 3.5% and 4.3%, respectively., Conclusion: The long-term outcomes after radical surgery for pT1 LRC are satisfactory or good, regardless of the presence or absence of LNM. In patients with pT1 LRC, the absence of visible mesorectal lymph nodes on preoperative CT and MRI is associated with a reduced likelihood of LNM and has a high negative predictive value for LNM.

Purpose: Concomitant meniscus injuries in the anterior cruciate ligament (ACL) have been suggested to exacerbate rotational laxity. However, the effect is supposed to be so small, if any, that some quantitative pivot-shift measurement is needed. The purpose of this prospective study was to determine the effect of meniscus tear on rotational laxity in ACL-deficient knees by an quantitative measurement. It was hypothesized that a concomitant meniscus tear, especially a lateral one, would induce greater pivot shift., Methods: Fifty-seven unilateral ACL-injured patients (26 men and 31 women, mean age: 24 ± 10 years) were included. The pivot-shift test was performed prior to ACL reconstruction, while a quantitative evaluation using an electromagnetic system to determine tibial acceleration and a clinical grading according to the IKDC were performed. Meniscus injuries were diagnosed arthroscopically, and concomitant meniscus tear was confirmed in 32 knees., Results: The clinical grade was not different between the ACL-injured knees of patients with and without meniscus tear (n.s.). Tibial acceleration did not show a statistical significant difference (meniscus-injured knees: 1.6 ± 1.1 m/s 2 versus meniscus-intact knees: 1.2 ± 0.7 m/s 2 , n.s.). However, the subgroup analysis demonstrated that there was increased tibial acceleration in ACL-deficient knees with lateral meniscus tear (2.1 ± 1.1 m/s 2 , n = 13) compared with meniscus-intact knees (p < 0.05), whereas rotational laxity did not increase in the medial meniscus-injured and bilateral-injured knees (1.2 ± 0.9 m/s 2 , n = 12, n.s. and 1.4 ± 1.1 m/s 2 , n = 7, n.s., respectively)., Conclusion: A concomitant meniscus tear, especially a lateral meniscus tear, has a significant impact on rotational laxity in ACL-injured knees. When a large pivot shift is observed in the ACL-injured knee, a concomitant meniscus tear should be suspected and an aggressive treatment would be considered. Meniscus injuries should be inspected carefully when substantial pivot shift is encountered in ACL-injured knees., Level of Evidence: Diagnostic study, Level III.

Purpose: This study aimed to clarify the frequency of distal spread and the optimal distal margin after preoperative chemotherapy for advanced low rectal cancer., Methods: The study included patients with advanced lower rectal cancer who received preoperative chemotherapy and underwent surgery during 2012-2015. We investigated the distal spread of tumor cells, defined as the distal distance from the intramucosal distal tumor edge to the farthest tumor cells located under the submucosal layer. Clinical characteristics were compared for distal spreads ≥ 10 and < 10 mm, and risk factors for distal spread ≥ 10 mm were investigated., Results: Of the 71 patients, 42 (59%) showed distal spread. Distal spreads of 1-9, 10-19, and ≥ 20 mm were observed in 27 (38%), 11 (15%), and 4 (6%) patients, respectively. Multivariate analysis revealed two independent risk factors for distal spread ≥ 10 mm after preoperative chemotherapy. The first risk factor is the presence of different therapeutic effects between the mucosal and deeper layers (meaning that superficial tumor shrinkage was evident on colonoscopy, but little tumor shrinkage was evident on magnetic resonance imaging) (odds ratio, 11.6; 95% CI, 2.22-61.3). The second risk factor is poorly differentiated or mucinous adenocarcinoma (odds ratio, 8.86; 95% CI, 1.58-49.9)., Conclusion: A distal margin of 20 mm is required (10 mm is insufficient) for advanced lower rectal cancer patients who receive preoperative chemotherapy followed by surgery. Independent risk factors for distal spread ≥ 10 mm include (1) the presence of different therapeutic effects between mucosal and deeper layers and (2) poorly differentiated or mucinous adenocarcinomas.

Purpose: Perineal wound infection (PWI) rates are high after abdominoperineal resection (APR) and total pelvic exenteration (TPE). This study identified risk factors for PWI after surgery for anorectal tumors and examined the relationship between the surgical excision volume with the PWI degree., Methods: A retrospective review involving 135 patients who underwent surgical excision of anorectal tumors was performed. Superficial PWI included cellulitis and superficial dehiscence; deep PWI included major dehiscence, perineal abscess, and presacral abscess. The adjacent organ resection type was classified according to the dead space size formed by surgical excision., Results: Of the 135 patients, 119 underwent APR, and 16 underwent TPE. PWI occurred in 75 patients (superficial PWI, 44; deep PWI, 31). Adjacent organ resection was an independent risk factor for PWI. The cases with adjacent organ resection were classified into small-defect APR, large-defect APR, and TPE. Large-defect APR and TPE cases had significantly higher rates of deep PWI than APR cases without adjacent organ resection., Conclusions: Adjacent organ resection involving the removal of one or more organs and that involving wide-range muscle resection are strong risk factors for deep PWI.

Purpose: Several non-invasive devices have been developed to obtain quantitative assessment of the pivot-shift test in clinical setting using similar but diverse measurement parameters. However, the clinical usability of those measurements has yet to be closely investigated and compared. The purpose of this study was to compare the diagnostic accuracy of three non-invasive measurement devices for the pivot-shift test., Methods: Thirty patients with unilateral anterior cruciate ligament (ACL) injury were enrolled. The pivot-shift test was performed under general anaesthesia. Three devices, an accelerometer system (KiRA), an image analysis iPad application (iPad), and electromagnetic measurement system (EMS), were used simultaneously to provide two parameters, namely tibial acceleration monitored using KiRA and EMS, and tibial translation recorded using iPad and EMS. Side-to-side differences in each parameter and correlation between the measurements were tested, and a receiver-operating characteristic (ROC) curve analysis was conducted to compare their measurement accuracy., Results: Significant side-to-side differences were successfully detected using any of the measurements (all p < 0.01). KiRA demonstrated moderate correlation with the EMS for tibial acceleration (r = 0.54; p < 0.01), while poor correlation was observed between iPad and the EMS for the translation (r = 0.28; p < 0.01). The ROC curve analysis demonstrated better accuracy for the detection of ACL insufficiency in the EMS than KiRA and iPad for tibial acceleration and translation, respectively., Conclusions: Although all three measurements were similarly capable of detecting ACL deficiency, the EMS has the advantage of comprehensive evaluation of the pivot-shift test by evaluating both tibial acceleration and translation with higher accuracy than those of KiRA and iPad. It could be suggested that any of those measurement tools might improve the clinical diagnosis of ACL insufficiency., Level of Evidence: Diagnostic study of consecutive patients with a universally applied gold standard, Level Ib.

Purpose: Final tunnel location in the anterior cruciate ligament (ACL) reconstruction is unpredictable due to tunnel widening and/or transposition. The mechanical stress around the tunnel aperture seems to be a major factor but is not fully investigated. The purpose of this study was to measure the stress from the ACL graft around the tunnel aperture when the ACL graft tension reaches its peak., Methods: Six cadaveric knees were used. Single-bundle ACL reconstruction was performed using a hamstrings graft. Both femoral and tibial tunnels were created at the centre of the original ACL footprint. A 7-mm-internal-diameter aluminium cylinder with pressure sensors was placed in the femoral tunnel. Hamstrings graft with a microtension sensor was inserted. After fixation, passive extension-flexion was performed while monitoring the tunnel aperture pressure and the graft tension simultaneously. The pressure on the femoral tunnel aperture when the ACL graft tension reach its peak was compared between four directions., Results: The ACL graft tension peaked (67 ± 49 N) at full extension (-5.8 ± 4.1°). Pressure at the femoral tunnel aperture was different between different directions (p < 0.01). Distal part had significantly larger pressure (1.7 ± 1.3 MPa) than the other directions (p < 0.01). Second largest pressure was carried in the anterior part (0.6 ± 0.5 MPa), followed by proximal and posterior parts (0.4 ± 0.3, 0.2 ± 0.2 MPa respectively)., Conclusion: The stress distribution at the femoral tunnel aperture is not equal in different directions, while the distal part dominantly bears the stress from the ACL graft. Surgeons should pay close attention to the distal edge of the femoral tunnel which should be inside the anatomic ACL footprint eventually.

Purpose: Sphincter-preserving operations performed with bladder-preserving surgery and a cystourethral anastomosis (CUA) do not require a urinary stoma, but leakage from the CUA may develop. The aim of this study was to evaluate the efficacy of performing an additional flap operation., Methods: The subjects were 39 patients who underwent bladder-preserving surgery for advanced rectal cancer involving the prostate, between 2001 and 2015.32 of whom had a CUA and one of whom had a neobladder. Five of these 32 patients underwent an ileal flap operation, 2 underwent an omental flap operation, and 3 underwent an operation using both flaps., Results: Leakage developed in 3 (30%) of the 10 patients who underwent additional flap operations, but in 14 (60.9%) of the 23 patients who did not undergo a flap operation. The mean periods of catheterization for the patients who suffered leakage were 31 weeks (8-108 weeks) in those without a flap and 16 weeks (8-20 weeks) in those with a flap. Four (33.3%) of the 12 patients with leakage after surgery without a flap had a period of urinary catheterization >30 weeks, and 2 (16.7%) had leakage of CTCAE grade 3. There were no cases of leakage after flap surgery., Conclusion: An additional flap operation may decrease the risk of leakage from a CUA.

Background: Data regarding anastomotic leakage (AL) following intersphincteric resection (ISR) are lacking. We aimed to evaluate the effect of AL on anal function in a retrospective review of patients who developed AL following ISR., Methods: We evaluated 341 consecutive patients who underwent ISR between 2000 and 2012. Patients were classified into three groups: anastomotic dehiscence (AD), major AL (Clavien-Dindo grade III+), or control (

Purpose: To propose a classification system for the shape of the tibial insertion site (TIS) of the anterior cruciate ligament (ACL) and to demonstrate the intra- and inter-rater agreement of this system. Due to variation in shape and size, different surgical approaches may be feasible to improve reconstruction of the TIS., Methods: One hundred patients with a mean age of 26 ± 11 years were included. The ACL was cut arthroscopically at the base of the tibial insertion site. Arthroscopic images were taken from the lateral and medial portal. Images were de-identified and duplicated. Two blinded observers classified the tibial insertion site according to a classification system., Results: The tibial insertion site was classified as type I (elliptical) in 51 knees (51 %), type II (triangular) in 33 knees (33 %) and type III (C-shaped) in 16 knees (16 %). There was good agreement between raters when viewing the insertion site from the lateral portal (κ = 0.65) as well as from the medial portal (κ = 0.66). Intra-rater reliability was good to excellent. Agreement in the description of the insertion site between the medial and lateral portals was good for rater 1 and good for rater 2 (κ = 0.74 and 0.77, respectively)., Conclusion: There is variation in the shape of the ACL TIS. The classification system is a repeatable and reliable tool to summarize the shape of the TIS using three common patterns. For clinical relevance, different shapes may require different types of reconstruction to ensure proper footprint restoration. Consideration of the individual TIS shape is required to prevent iatrogenic damage of adjacent structures like the menisci., Level of Evidence: III.

Purpose: We introduce a novel transanal tube (TAT), named the "WING DRAIN", designed to prevent anastomotic leakage after rectal cancer surgery, and report the fundamental experiments that led to its development., Materials and Methods: We performed the basic experiments to evaluate the effect of TATs on intestinal decompression, the changes they make in patterns of watery fluid drainage, the changes in their decompression effect when the extension tube connecting the TAT to the collection bag fills with watery drainage fluid, and the variations in intestinal contact and crushing pressure made by some types of TAT., Results: Any type of TAT contributed to decompression in the intestinal tract. Watery drainage commenced from when the water level first rose to the hole in the tip of drain. The intestinal pressure increased with the length of the vertical twist in an extension tube. The crushing pressures of most types of TAT were high enough to cause injury to the intestine., Conclusions: We resolved the problems using an existing TAT for the purpose of intestinal decompression and by creating the first specialized TAT designed to prevent anastomotic leakage after rectal cancer surgery in Japan.

Purpose: To examine the clinical and biomechanical results of posterolateral (PL) augmentation to reconstruct damaged PL bundle while preserving the less-damaged anteromedial bundle for partial anterior cruciate ligament (ACL) tears in comparison with double-bundle ACL reconstruction., Methods: Sixteen patients who underwent PL augmentation for partial ACL tears (Group P) and 37 patients who underwent double-bundle ACL reconstructions for complete ACL tears were examined (Group D). Anterior tibial translation (ATT) was evaluated using the KT-1000 arthrometer. ATT during the Lachman test and acceleration of posterior tibial translation (APT) during the pivot shift test were evaluated using an electromagnetic measurement system (EMS). Clinical outcomes were evaluated using the Lysholm score. Second-look arthroscopy was performed 1 year after surgery., Results: The mean postoperative Lysholm scores were 91.7 ± 12.2 and 94.6 ± 7.2 in Groups P and D, respectively, and there was no statistically significant difference between the two groups. The mean side-to-side difference of ATT on the KT-1000 was significantly improved in both Groups P and D. In the EMS analysis, the mean side-to-side difference of ATT and the mean APT were significantly improved in both Groups P and D. There was no significant difference in the second-look evaluation between the two groups., Conclusions: The clinical and biomechanical outcomes of PL augmentation were satisfactorily comparable to those of double-bundle ACL reconstruction. PL augmentation could be a useful treatment option for patients with partial ACL tears., Level of Evidence: IV.

Purpose: 3D images offer true depth perception, which overcomes one of the disadvantages of laparoscopic surgery. We evaluated differences in the use of 3D and 2D images in laparoscopic surgery based on the recording of traces of forceps., Methods: Twelve surgeons at our hospital participated in the study. The task consisted of one suture and three ligations, using a training box. The completion time and number of hold errors were noted, and forceps traces were recorded using the Behavior Checker system (Miura Medical). Participants were divided into two groups based on faster and slower completion times with 2D images., Results: The median completion time in seconds (s) was significantly shorter when using 3D images than when using 2D images (51 s, range 34-146 vs. 63 s, range 38-265 s; p = 0.013). The 3D/2D completion time ratio was significantly higher in the faster 2D group (0.93 vs. 0.69, p = 0.030) indicating a greater effect of the 3D images on less experienced participants., Conclusions: A quantitative evaluation showed that using 3D images enables more efficient use of laparoscopic forceps than 2D images. A system with 3D images is of particular benefit for inexperienced surgeons.

Purpose: Neoadjuvant chemoradiotherapy (CRT) for rectal cancer improves local control but also induces severe postoperative anal dysfunction that may be related to neural degeneration. The aims of the study were to identify pathological features of neural degeneration caused by neoadjuvant CRT or neoadjuvant chemotherapy (NAC) and to evaluate the association between neural degeneration and anal function., Methods: A retrospective study using chronologically different groups was performed in 95 patients with rectal cancer treated with curative resection with neoadjuvant CRT (n = 47), NAC (n = 27), or surgery alone (no neoadjuvant therapy) (n = 21) at National Cancer Center Hospital East from 2001 to 2014. Peripheral nerve degeneration was evaluated histopathologically using H&E stained sections, based on karyopyknosis, vacuolar or acidophilic degeneration, denucleation, adventitial neuron change, and fibrosis. Morphological analysis of peripheral nerves was compared among the three groups. The association between pathological features and anal function (Wexner Score) was evaluated., Results: After CRT, the degree of fibrosis around the tumor was severe, and neural degeneration was found in peripheral neurons. With NAC and surgery alone, there was little fibrosis and neural degeneration. Pathological changes after CRT were more pronounced than those after NAC, indicating greater tissue degeneration due to CRT. There was an association between anal function and degeneration score in the CRT group, but not in the other groups., Conclusions: Peripheral nerves in patients who received neoadjuvant CRT showed characteristic pathological features indicating greater degeneration, compared with patients who received NAC. Neural degeneration is associated with anal function and several pathological factors after CRT.

Purpose: Postoperative sexual and urinary dysfunction may occur after rectal cancer surgery involving the pelvis, but this problem cannot be solved. The aim of this study was to examine the nerve morphology of the neurovascular bundle in cadavers to determine possible causes of nerve damage during surgery., Methods: Twenty-two formalin-fixed cadavers were used in the study. The cadavers were donated to the Tokyo Medical University. The study comprised histological evaluation of paraffin-embedded bilateral neurovascular bundle specimens from the cadavers. Four slides of 3-cm thick were made every 1 cm in a plane perpendicular to the rectum towards the pelvic floor from the peritoneal reflection in bilateral neurovascular bundles in 22 cadavers. The number of nerves, the mean nerve area, and the mean nerve diameter were measured in each slide., Results: The results were categorized into cases with high (group H) and low (group L) positions of the pelvis 1 cm above and 2 cm below the peritoneal reflection, respectively. There was no significant difference in the number of nerves between these groups. The nerve area and nerve diameter were significantly smaller in group L, and these characteristics were more marked in males., Conclusions: Our results show that the nerves of the neurovascular bundle became smaller in the deep pelvis. This may cause these nerves to be more susceptible to injury, resulting in nerve damage in the deep pelvis that leads to postoperative dysfunction. Particularly, this type of nerve damage may be a cause of postoperative sexual dysfunction in males.

Purpose: Tibial acceleration during the pivot shift test is a potential quantitative parameter to evaluate rotational laxity of anterior cruciate ligament (ACL) insufficiency. However, clinical application of this measurement has not been fully examined. This study aimed to measure and compare tibial acceleration before and after ACL reconstruction (ACLR) in ACL-injured patients. We hypothesized tibial acceleration would be reduced by ACLR and tibial acceleration would be consistent in the same knee at different time points., Methods: Seventy ACL-injured patients who underwent ACLR were enrolled. Tibial acceleration during the pivot shift test was measured using an electromagnetic measurement system before ALCR and at the second-look arthroscopy 1 year post-operatively. Tibial acceleration was compared to clinical grading and between ACL-injured/ACL-reconstructed and contralateral knees., Results: Pre-operative tibial acceleration was increased stepwise with the increase in clinical grading (P < 0.01). Tibial acceleration in ACL-injured knee (1.9 ± 1.2 m/s(2)) was larger than that in the contralateral knee (0.8 ± 0.3 m/s(2), P < 0.01), and reduced to 0.9 ± 0.3 m/s(2) post-operatively (P < 0.01). There was no difference between ACL-reconstructed and contralateral knee (n.s.). Tibial acceleration in contralateral knees was consistent pre- and post-operatively (n.s.)., Conclusion: Tibial acceleration measurement demonstrated increased rotational laxity in ACL-injured knees and its reduction by ALCR. Additionally, consistent measurements were obtained in ACL-intact knees at different time points. Therefore, tibial acceleration during the pivot shift test could provide quantitative evaluation of rotational stability before and after ACL reconstruction., Level of Evidence: III.

Background: Pulmonary resection is the best therapeutic option for lung metastases from colorectal cancer (CRC) today. However, recurrences are frequent following pulmonary resection. We aimed to evaluate the recurrence pattern and treatment of initial pulmonary resection for metastases from CRC., Methods: Data from 76 patients with recurrence after curative resection of primary CRC and lung metastases were reviewed. The primary outcome measure was overall survival (OS), defined as the interval between the date of recurrence after pulmonary resection and the date of death or last follow-up. Cox regression analyses were performed to identify the factors associated with OS., Results: Recurrence sites after initial pulmonary resection were lung (n = 37), liver (n = 12), others (n = 11), and multiple (n = 16). Treatments for recurrence included surgery (n = 35), chemotherapy (n = 37), and palliative care (n = 4). Of 35 patients who underwent surgery, 22 had pulmonary resection, and 11 had hepatic resection, and 2 had other resection. The 3-year OS was 84.1 % for surgery, 38.9 % for chemotherapy, and 0 % for palliative care, respectively (p < 0.001). In the surgery group, there was no difference in survival between surgical treatments for pulmonary and hepatic recurrences (p = 0.503). Cox regression analyses identified three factors: disease-free interval (DFI) (HR 1.99, 95 % CI 1.03-3.83), surgery (HR 0.30, 95 % CI 0.12-0.72), and recurrence site (lung: HR 0.10, 95 % CI 0.04-0.28, liver: HR 0.08, 95 % CI 0.02-0.31)., Conclusions: The most common recurrence site after resection of lung metastases was the lung. Although the relapse rate is high, surgery for isolated recurrences is a promising strategy, especially for patients with long DFI.

Aim: We evaluated the effectiveness and safety of a transanal tube placed for the prevention of anastomotic leakage after rectal surgery., Methods: Between 2007 and 2011, a total of 243 patients underwent anterior resection using the double stapling technique for rectal cancer at our institution. We excluded 67 patients with diverting stoma and divided the remaining patients into two groups: patients who did not receive a transanal tube and diverting stoma (n = 140; control group) and those who received a transanal tube (n = 36). We compared the rate of anastomotic leakage, evaluated the complications associated with the transanal tube, and analyzed the risk factors for anastomotic leakage., Results: The following perioperative parameters were significantly different between the two groups as follows (control group vs. transanal tube group): diabetes mellitus (8 [22 %] vs. 12 [8.5 %] patients, respectively; p = 0.03), surgical duration (262 ± 54.1 min [171-457] vs. 233 ± 61.7 min [126-430], respectively; p < 0.01). The postoperative anastomosis leakage appeared significantly different between the two groups (1 [2.7 %] vs. 22 [15.7 %] patients, respectively; p = 0.04). Anastomotic leakage was significantly associated with the distance between the anastomosis line and the anal verge (odds ratio [OR] 8.58; 95 % confidence interval [CI] 1.53-48.0; p = 0.01) and non-use of a transanal tube (OR 11.1; 95 % CI 1.04-118; p = 0.04) in both univariate and multivariate analyses., Conclusions: Placement of a transanal tube is effective in decreasing the rate of anastomotic leakage after anterior resection using the double stapling technique. However, complications associated with a transanal tube should be carefully considered.

Summary: Once-weekly administration of 56.5 μg teriparatide improved cortical bone parameters and biomechanical parameters at the proximal femur by CT geometry analysis., Introduction: The aim of this study was to evaluate the effects of weekly administration of teriparatide [human PTH (1-34)] on bone geometry, volumetric bone mineral density (vBMD), and parameters of bone strength at the proximal femur which were longitudinally investigated using computed tomography (CT)., Methods: The subjects were a subgroup of a recent, randomly assigned, double-blind study (578 subjects) comparing the anti-fracture efficacy of a once-weekly subcutaneous injection of 56.5 μg teriparatide with placebo (TOWER trial)., Results: Sixty-six ambulatory postmenopausal women with osteoporosis were enrolled at 15 study sites having multi-detector row CT, and included women injected with teriparatide (n = 29, 74.2 ± 5.1 years) or with placebo (n = 37, 74.8 ± 5.3 years). CT data were obtained at baseline and follow-up scans were performed at 48 and 72 weeks. The data were analyzed to obtain cross-sectional densitometric, geometric, and biomechanical parameters including the section modulus (SM) and buckling ratio (BR) of the femoral neck, inter-trochanter, and femoral shaft. We found that once-weekly teriparatide increased cortical thickness/cross-sectional area (CSA) and total area, and improved biomechanical properties (i.e., decreasing BR) at the femoral neck and shaft. Teriparatide did not change the cortical perimeter., Conclusions: Our longitudinal analysis of proximal femur geometry by CT revealed that once-weekly administration of 56.5 μg teriparatide improved cortical bone parameters at the femoral neck and shaft and also improved biomechanical parameters.

Background: Delayed gastric emptying (DGE) is a common complication following left-sided hepatectomy. The goal of this study was to clarify the clinical implications of an omental flap wrapping procedure that includes fixation to the cut surface of the liver to reduce the incidence of DGE after left-sided hepatectomy., Methods: The study included 50 consecutive patients who underwent left-sided hepatectomy between January 2000 and July 2011. Clinicopathologic risk factors for DGE after left-sided hepatectomy were identified using univariate and multivariate models. The incidence of DGE, digestive symptoms, and postoperative complications were compared between two groups: 25 patients treated with the omental flap wrapping and fixation procedure and 25 patients who did not receive such a flap., Results: A univariate analysis revealed that a lack of the omental flap, the lymph node clearance, and use of left hemihepatectomy were associated with postoperative DGE. The multivariate analysis indicated that the lack of the omental flap was the only independent significant factor associated with the DGE (odds ratio, 21.23; p = 0.0002). There was a significant difference in the incidence of DGE between the patients with (4 %) and without an omental flap (36 %). The incidence of gastric distension and the use of prokinetic drugs were also significantly lower in patients with an omental flap than in patients without the flap, and patients with an omental flap resumed a solid diet significantly earlier., Conclusions: This retrospective single-center study revealed that it was possible to reduce the incidence of DGE using a procedure involving omental flap wrapping with fixation to the cut surface of the liver after left-sided hepatectomy.

A rectoseminal vesicle fistula is a rare complication after a low anterior resection for rectal cancer, usually developing in the outpatient postoperative period with pneumaturia, fever, scrotal swelling or testicular pain. A diagnostic water-soluble contrast enema, cystography and computed tomography reveal a tract from the rectum to the seminal vesicle. Anastomotic leakage is thought to be partially responsible for the formation of such tracts. This report presents three cases of rectoseminal vesicle fistula, and the presumed course of the disease and optimal treatment options are discussed.

Summary: Increased levels of serum undercarboxylated osteocalcin, which were associated with bone metabolism markers, correlated inversely with indices of glucose metabolism (plasma glucose, hemoglobin A1C, and glycated albumin) in hemodialysis patients with abnormalities of bone metabolism., Introduction: Undercarboxylated osteocalcin (ucOC), a possible marker of bone metabolism and one of the osteoblast-specific secreted proteins, has recently been reported to be associated with glucose metabolism. We tested the hypothesis that ucOC levels are associated with indices of glucose metabolism in chronic hemodialysis patients with abnormalities of bone metabolism., Methods: Serum ucOC, bone alkaline phosphatase (BAP, a bone formation marker), and tartrate-resistant acid phosphatase-5b (TRACP-5b, a bone resorption marker) were measured in 189 maintenance hemodialysis patients (96 diabetics and 93 non-diabetics), and their relationships with glucose metabolism were examined., Results: ucOC correlated positively with BAP (ρ = 0.489, p < 0.0001), TRACP-5b (ρ = 0.585, p < 0.0001) and intact parathyroid hormone (iPTH; ρ = 0.621, p < 0.0001). Serum ucOC levels in the diabetic patients were lower than those of non-diabetic patients (p < 0.001), although there were no significant differences in serum BAP or TRACP-5b between diabetic and non-diabetic patients. Serum ucOC correlated negatively with plasma glucose (ρ = -0.303, p < 0.0001), hemoglobin A1C (ρ = -0.214, p < 0.01), and glycated albumin (ρ = -0.271, p < 0.001), although serum BAP or TRACP-5b did not. In multiple linear regression analysis, log [plasma glucose], log [hemoglobin A1C], and log [glycated albumin] were associated significantly with log [ucOC] after adjustment for age, gender, hemodialysis duration, and body mass index but were not associated with log [BAP], log [TRACP-5b], or log [intact PTH]., Conclusion: Increased levels of serum ucOC, which were associated with bone metabolism markers, were inversely associated with indices of glucose metabolism in hemodialysis patients.

Purpose: Preoperative chemoradiotherapy (CRT) for rectal cancer is administered to improve local control, but can also induce severe anal dysfunction after surgery, while preoperative chemotherapy that significantly reduces the primary lesion in rectal cancer has recently been developed. The aim of the study was to examine differences in the effects of preoperative CRT and chemotherapy on tissue degeneration of patients with colorectal cancer., Methods: The subjects were 91 patients, including 68 with rectal cancer who underwent internal sphincteric resection with (n = 47, CRT group) or without (n = 21, control group) preoperative CRT, and 23 with colorectal cancer who received preoperative FOLFOX treatment. Peripheral nerve degeneration was evaluated histopathologically using H&E-stained sections, based on karyopyknosis, disparity of the nucleus, denucleation, vacuolar or acidophilic degeneration of the cytoplasm, and adventitial neuronal changes., Results: The incidence of neural degeneration was significantly higher in the CRT group than in the control group and FOLFOX group. There were no differences in any items of neural degeneration between the FOLFOX and control groups., Conclusion: CRT induced marked neural degeneration around the rectal tumor. FOLFOX treatment produced mild neural degeneration similar to that in the control group.

Purpose: To evaluate the diagnosis, epidemiology, risk factors, and treatment of chylous ascites after colorectal cancer surgery., Methods: Among 907 patients who underwent colorectal cancer resection at our institution between 2006 and 2009, chylous ascites developed in 9. We analyzed the clinical data for these 9 patients., Results: Five of the nine patients with chylous ascites had undergone right hemicolectomy and seven had undergone D3 lymph node dissection. In all patients, chylous ascites began to develop the day after commencement of oral intake or the next day. Two patients had no change in diet, one was started on a high-protein and low-fat diet, and six were put on intestinal fasting. Drainage tubes were removed within 5 days after treatment in seven patients. The hospital stay was about 2 weeks after surgery and 1 week after treatment. We found that the tumor area, tumors fed by the superior mesenteric artery, and D3 lymph node dissection were significantly associated with chylous ascites., Conclusions: Chylous ascites after colorectal cancer surgery occurred at an incidence of 1.0%, but was significantly more frequent after surgery for tumors fed by the superior mesenteric artery and after D3 lymph node dissection. Conservative treatment was effective in all cases.

Summary: Bone mineral density of the 1/3 distal radius, ultra-distal radius, and lumbar spine correlated significantly and negatively with serum adiponectin. There was a significant positive correlation between serum adiponectin and serum NTX. Thus, adiponectin may play a role in mineral and bone disorder in chronic kidney disease stage 5 dialysis (CKD 5D) patients., Introduction: Serum adiponectin, an adipocyte-produced hormone, has been reported to correlate negatively with bone mineral density (BMD) in the general population. However, little is known about the association between adiponectin and BMD in patients with CKD., Methods: BMD of the 1/3 distal and ultra-distal radius, which are enriched with cortical and cancellous bone, respectively, and the lumbar spine was measured by dual X-ray absorptiometry in 114 Japanese male hemodialysis patients (age 61.0 ± 11.1 years; hemodialysis duration 6.6 ± 3.0 years; 43.9% diabetics). Serum total adiponectin, bone formation marker (bone alkaline phosphatase, BAP), and bone resorption marker (cross-linked N-telopeptide of type I collagen (NTX)) were measured., Results: The BMD of the 1/3 distal radius, ultra-distal radius, and lumbar spine correlated significantly and negatively with serum adiponectin level (r = -0.229, p = 0.014; r = -0.286, p = 0.002; r = -0.227, p = 0.013, respectively). In multiple linear regression analyses, serum adiponectin was significantly and independently associated with the BMD of the 1/3 distal radius (R(2) = 0.173, p < 0.001) and ultra-distal radius (R(2) = 0.278, p < 0.001) after adjustment of age, hemodialysis duration, body weight, %fat mass, and log [intact PTH], although it was not with the BMD of the lumbar spine. There was a significant positive correlation between serum adiponectin and serum NTX (r = 0.321, p < 0.001), although there was no significant correlation between serum adiponectin and serum BAP., Conclusion: Increased levels of serum adiponectin were associated with decrease in BMD in male hemodialysis patients. Adiponectin may play a role in mineral and bone disorder, possibly in bone resorption, of patients with CKD 5D.

Unlabelled: Monthly minodronate at 30 or 50 mg had similar efficacy as 1 mg daily in terms of change in bone mineral density (BMD) and bone turnover markers with similar safety profiles. This new regimen provides patients with a new option for taking minodronate., Introduction: Minodronate at a daily oral dose of 1 mg has been proven to have antivertebral fracture efficacy. In the present study, the efficacy and safety of oral minodronate at monthly doses of either 30 mg or 50 mg were compared with a daily dose of 1 mg., Methods: A total of 692 patients with involutional osteoporosis were randomized to receive minodronate at either 30 or 50 mg monthly or a daily dose of 1 mg. The primary endpoint was the percent change from baseline in lumbar spine (LS) BMD at 12 months. Total hip BMD, bone turnover markers, serum calcium (Ca), and parathyroid hormone (PTH) levels were also evaluated., Results: Minodronate at monthly doses of 30 or 50 mg were noninferior to the 1 mg daily dose in terms of change in LS-BMD. Changes in total hip BMD were also comparable. Although a transient decrease in serum Ca and increase in PTH levels were observed in all three groups at slightly different magnitudes and time courses, changes in bone turnover markers were comparable among the different dosage groups with a similar time course. Safety profiles were also comparable., Conclusion: Minodronate at monthly doses of 30 or 50 mg has similar efficacy to the daily 1 mg dose in terms of BMD and bone turnover markers with similar tolerability.

Static load-displacement measurement is unrelated to the dynamic knee function of anterior cruciate ligament (ACL) insufficiency. Performing an accurate, dynamic functional evaluation is necessary not only for the primary ACL injury, but also as an outcome measurement in ACL reconstruction. The pivot shift test is commonly used for assessing dynamic rotatory knee laxity in ACL-insufficient knees and is related to subjective knee function. Residual pivot shift after ACL reconstruction is a crucial factor related to poor clinical outcome. However, the pivot shift test is subjectively determined by the examiners' hands. Not only 3-dimensional (3D) position displacement but also its 3D acceleration should be measured for quantitative evaluation of the pivot shift test and is currently feasible by using recent advanced technology, i.e., electromagnetic devices. We summarize the basic knowledge and current concepts of quantitative exploration of the dynamic knee movement during the pivot shift test.

Purpose: To investigate the treatment and outcomes in a series of seven cases of small bowel metastases from lung cancer., Methods: A total of 4114 patients with lung cancer were referred to this institution from 1995 to 2005. Seven (0.17%) developed symptomatic small bowel metastasis and were treated surgically. The clinical, radiological, and pathological records were reviewed., Results: Small bowel metastases were diagnosed from 0 to 31 months (mean 11.5 months) after the diagnosis of lung cancer. The clinical symptoms at presentation were acute peritonitis in two patients and abdominal pain in five. Small bowel metastasis was suspected on abdominal X-ray in three cases, computed tomography in two, small bowel radiography in one, and endogastroduodenoscopy in one. All patients underwent surgery and there were no perioperative deaths. Intestinal resection was performed in five cases and a bypass in two. A small bowel metastasis was found in the ileum in four patients. The mean survival period was 7.7 months after surgery. One patient lived for 22 months after bowel resection. Oral intake was possible 1 month after surgery in six cases., Conclusion: Surgical management should be considered as palliative treatment in patients with a bowel obstruction or peritonitis caused by primary lung cancer.

Purpose: The aims of the study were to determine the extent of male sexual dysfunction after surgical treatment of rectal cancer and to examine the outcome of postoperative treatment with sildenafil., Methods: A prospective study was performed in patients who underwent attempted curative total mesorectal excision (TME) for low rectal cancers. Sexual function scores were determined by questionnaire preoperatively and at 3 and 12 months postoperatively. Outcomes were examined in patients who were sexually active preoperatively., Results: From 2000 to 2007, 207 patients underwent TME at our institution, of whom 49 (24%) were sexually active preoperatively. Erectile dysfunction and ejaculatory problems were present in 80% and 82%, respectively of the 49 patients at 3 months postoperatively, and in 76% and 67%, respectively at 12 months. Lateral lymph node dissection was a strong risk factor for postoperative sexual dysfunction. The impotency rate was 37% and 47% of patients were unable to ejaculate. Sildenafil was administered to 16 patients who requested the drug during follow-up, and sexual dysfunction was improved in 11 of these patients (69%)., Conclusion: Sexual dysfunction occurs frequently after rectal cancer treatment and is mainly caused by surgical damage in lateral lymph node dissection. Sildenafil may be effective for the treatment of sexual dysfunction.

Background: Intralesional or systemic steroid administration is a promising strategy for the prevention of esophageal stricture after endoscopic therapy. The aim of this study was to evaluate the influence of steroid therapy on the process of healing of defects in the esophageal mucosa after endoscopic mucosal resection (EMR)., Methods: Nine beagle dogs were divided into three equal groups: group A, intralesional injection (n = 3), group B, peroral administration (n = 3), and group C, untreated control (n = 3). In group A, triamcinolone acetonide 1 ml (10 mg) was injected directly into the exposed submucosal layer immediately after EMR, and again on postoperative day (POD) 7. In group B, dogs were administered prednisolone 0.5 mg/kg/day orally for 14 days after EMR. In group C, 1 ml normal saline was injected by the same method as that used for group A. On POD 28, histological examination was performed to evaluate epithelialization, inflammation, angiogenesis, and atrophy of the muscularis propria., Results: In groups A, B, and C, the mean ulcer area was 50.1, 22.7, and 7.4 mm(2), respectively. The difference between groups A and C was significant (p < 0.01). Inflammatory cells were significantly more evident in the lesions of group A than in those of group C (p < 0.05). In all groups, atrophy of the muscularis propria was evident. However, transmural destruction and fibrosis were observed only in group A., Conclusion: It was speculated that the esophageal ulcer causes the fibrosis of the submucosa and atrophy of the muscularis propria during process of healing. Intralesional steroid injection deepened the esophageal ulcers and delayed epithelialization, whereas systemic administration did not clearly improve the lesion healing process.

Purpose: This study was performed to investigate the effect of subcuticular sutures on the incidence of incisional surgical site infection (SSI) after closure of a diverting stoma., Methods: The study was carried out as a retrospective analysis of prospectively collected data from 51 patients who underwent closure of diverting stoma following resections of lower rectal cancer between January 2008 and December 2008. This study attempted to determine whether there was an association between the type of skin closure and the incidence of incisional SSI. Moreover, risk factors for incisional SSI after closure of diverting stoma were identified using a multivariate analysis., Results: An incisional SSI occurred in 12 of the 51 patients (23.5%). The rate of incisional SSI with subcuticular sutures was 11.1% (3/27) in comparison to 37.5% (9/24) with transdermal suture and skin stapler. A subcuticular skin closure was the only favorable factor that was significantly associated with a lower incidence of incisional SSI (odds ratio: 0.19; 95% confidence interval: 0.04-0.92)., Conclusions: A subcuticular skin closure has a protective effect against incisional SSI after closure of diverting stoma. A larger study is necessary to further define the role of subcuticular suture on the prevention of incisional SSI in cases of gastrointestinal surgery.

Unlabelled: In cinacalcet treatment of hemodialysis (HD) patients with secondary hyperparathyroidism (SHPT), not only intact parathyroid hormone (I-PTH), whole PTH (W-PTH), and bone markers, but also W-PTH/I-PTH ratio as proportion of active PTH(1-84) molecules were decreased. Changes in W-PTH/I-PTH ratio significantly correlated and predicted changes in bone marker., Introduction: Cinacalcet partly suppresses the secretion of PTH by enhancing PTH(1-84) degradation into N-truncated fragments. The objectives of this study is to investigate the significance of the N-truncated PTH/PTH(1-84) ratio for the prediction of the effect of cinacalcet in HD patients., Methods: Serum parameters were measured during 12 weeks of oral cinacalcet administration at 25 mg daily in 39 HD patients with SHPT., Results: Serum Ca, Pi, W-PTH, I-PTH, and W-PTH/I-PTH ratio all decreased significantly in a time-dependent manner during cinacalcet administration. Serum tartrate-resistant acid phosphatase (TRAP) 5b reflected these changes more precisely than serum N-telopeptide of type-I collagen. At 1 week, changes in I-PTH and W-PTH correlated significantly with those in serum Pi, but not Ca. Changes in serum Pi (but not Ca) and serum W-PTH also correlated significantly with changes in serum TRAP5b at both 4 and 12 weeks, while changes in serum I-PTH correlated significantly with those in serum TRAP5b only at 12 weeks. Changes in the serum W-PTH/I-PTH ratio correlated significantly with those in serum TRAP5b at both 4 and 12 weeks, and changes in serum W-PTH/I-PTH ratio at 4 weeks showed a tendency for a correlation with changes in serum TRAP5b at 12 weeks. HD patients with a reduced W-PTH/I-PTH ratio after 4 weeks had a significantly greater reduction of TRAP5b over 12 weeks., Conclusion: W-PTH and the W-PTH/I-PTH ratio allow estimation of the potency of cinacalcet in enhancement of PTH degradation, and thus no less reliable markers than I-PTH for reflecting cinacalcet-induced bone resorption.

Background: In 2000 we launched a prospective program of intersphincteric resection (ISR) for very low rectal cancer. In this study we compared the oncologic outcome of patients who underwent ISR with the outcome of patients who underwent abdominoperineal resection (APR)., Methods: The data of 202 patients with very low rectal cancer who underwent curative ISR (n = 132) or curative APR (n = 70) between 1995 and 2006 were analyzed. Patients were divided into ISR and APR groups. Survival and local recurrence were investigated in both groups., Results: The median follow-up was 40 months in the ISR group and 57 months in the APR group. The 5-year local relapse-free survival rate was 83% in the ISR group and 80% in the APR group (p = 0.364), and the 5-year disease-free survival rate was 69% in the ISR group and 63% in the APR group (p = 0.714)., Conclusions: For very low rectal cancers, ISR appears to be oncologically acceptable and can reduce the number of APRs.

Background: We experienced some technical difficulty in dividing the middle and lower rectum through the right-lower quadrant intracorporeally. The aim of this study was to determine whether multiple stapler firings during rectal division are associated with anastomotic leakage after laparoscopic rectal resection., Methods: Laparoscopic anterior resection with double-stapling technique anastomosis was performed in 180 consecutive rectal cancer patients. We often used vertical rectal division through a suprapubic site instead of the standard transverse rectal division for laparoscopic total mesorectal excision (LapTME). We attempted to determine whether there was an association between the number of stapler firings and procedures in rectal division. Moreover, we identified risk factors for anastomotic leakage after laparoscopic rectal resection by multivariate analysis., Results: Anastomotic leakage occurred in 5% of the subjects of this study. Vertical rectal division through the suprapubic site after Lap TME required fewer staples than transverse division through the right-lower port and a smaller percentage of patients required three or more staples for vertical rectal division than for transverse division (15% vs. 45%, p=0.03). In the multivariate analysis, TME and the number of staplers used for rectal division were the factors found to be associated with a significantly greater risk of subsequent leakage (odd's ratio=5.3; 95% CI 1.2-22.7 and odd's ratio=4.6; 95% CI 1.1-19.2)., Conclusion: TME and multiple stapler firings during distal rectal division were associated with anastomotic leakage after laparoscopic rectal resection. Vertical rectal division through a suprapubic site was a useful method of avoiding multiple stapler firings during laparoscopic TME.

Unlabelled: As the serum calcium and glomerular filtration rate decreased, the proportion of active PTH(1-84) molecules in PTH immunoreactivity increased in serum from predialysis uremic patients, particularly those with vitamin D insufficiency., Introduction: The PTH(1-84) fraction was altered in predialysis patients with chronic renal failure (CRF)., Methods: Serum PTH in predialysis CRF patients without any medication was measured by PTH(1-84)-specific whole PTH assay and intact PTH assay cross-reacting with N-truncated PTH., Results: In CRF patients, the glomerular filtration rate (GFR) correlated positively with serum Ca and 1,25-dihydroxyvitamin D (1,25(OH)(2)D), and inversely with serum Pi, log intact PTH, and log whole PTH. In multiple regression analysis, including age, gender, body mass index, GFR, Ca, and Pi and 1,25(OH)(2)D as independent variables, serum Ca and GFR associated significantly with serum log whole PTH and intact PTH. Serum log whole PTH/intact PTH ratio, which increased as serum Ca and GFR decreased, retained a negative correlation in those with serum 25-hydroxyvitamin D levels below 20 ng/ml, but not in those above 20 ng/ml. The ratio also correlated positively with serum log tartrate-resistant acid-phosphatase-5b, log cross-linked N-telopeptide of type-I collagen, and log bone alkaline-phosphatase., Conclusion: As GFR declined with suppression of serum Ca, the proportion of active PTH molecules increased in predialysis CRF patients, particularly those with vitamin D insufficiency.

Purpose: Total pelvic exenteration (TPE) is the standard procedure for locally advanced rectal cancer involving the prostate and seminal vesicles. We evaluated the feasibility of bladder-sparing surgery as an alternative to TPE., Methods: Eleven patients with advanced primary or recurrent rectal cancer involving the prostate or seminal vesicles, or both, underwent bladder-sparing extended colorectal resection with radical prostatectomy. The procedures performed were abdominoperineal resection (APR) with prostatectomy (n = 6), colorectal resection using intersphincteric resection combined with prostatectomy (n = 4), and abdominoperineal tumor resection with prostatectomy (n = 1). Local control and urinary and anal function were evaluated postoperatively., Results: Cysto-urethral anastomosis (CUA) was performed in seven patients and catheter-cystostomy was performed in four patients. Coloanal or colo-anal canal anastomosis was also performed in four patients. There was no mortality, and the morbidity rate was 38%. All patients underwent complete resection with negative surgical margins. After a median follow-up period of 26 months there was no sign of local recurrence, and ten patients were alive without disease, although distant metastases were found in three patients. Five patients had satisfactory voiding function after CUA, and three had satisfactory evacuation after intersphincteric resection (ISR)., Conclusion: These bladder-sparing procedures allow conservative surgery to be performed in selected patients with advanced rectal cancer involving the prostate or seminal vesicles, without compromising local control.

Introduction: Fibroblast growth factor (FGF) 23 is a recently identified circulating factor that regulates phosphate (Pi) metabolism. Since the derangement of Pi control is an important risk factor for vascular calcification, we investigated the importance of plasma FGF-23 in the development of vascular calcification in the aorta and peripheral artery in hemodialysis patients with and without diabetes mellitus (DM)., Methods: Male hemodialysis patients with DM (n=32) and without DM (n=56) were examined. Plasma samples were obtained before the start of dialysis sessions, and the FGF-23 levels were determined by enzyme-linked immunosorbent assay. Roentgenography of the aorta and hand artery was performed, and visible vascular calcification was evaluated by one examiner, who was blinded to the patient characteristics., Results: In the 56 non-DM hemodialysis patients, vascular calcification was found in the hand artery in 5 patients (8.9%) and in the aorta in 23 patients (41.1%). These levels were significantly lower (p<0.05) than in the 32 DM patients, of whom, 19 (59.4%) and 21 (65.6%) had vascular calcification of the hand artery and aorta, respectively. Multiple regression analyses performed separately in the non-DM and DM patients showed that the plasma FGF-23 level, CaxPi product, and body weight are independent factors significantly associated with hand-artery calcification and that diastolic blood pressure is associated with aorta calcification in non-DM patients. In DM patients, the plasma FGF-23 level and hemodialysis duration emerged as independent factors associated with hand-artery calcification and diastolic blood pressure was associated with aorta calcification. The independent association of the plasma FGF-23 level with hand-artery calcification was retained in both non-DM and DM patients when adjusted for the CaxPi product., Conclusion: Our findings show that the plasma FGF-23 level is an independent factor negatively associated with peripheral vascular calcification in the hand artery, but not in the aorta, in both male non-DM and DM hemodialysis patients, even when adjusted for the CaxPi product. This study raises the possibility that the plasma FGF-23 level may provide a reliable marker for Moenckeberg's medial calcification in male hemodialysis patients, independent of its regulatory effect on Pi metabolism.

Various auxotrophic mutants of diploid heterothallic Japanese sake strains of Saccharomyces cerevisiae were utilized for selecting mating-competent diploid isolates. The auxotrophic mutants were exposed to ultraviolet (UV) irradiation and crossed with laboratory haploid tester strains carrying complementary auxotrophic markers. Zygotes were then selected on minimal medium. Sake strains exhibiting a MATa or MATalpha mating type were easily obtained at high frequency without prior sporulation, suggesting that the UV irradiation induced homozygosity at the MAT locus. Flow cytometric analysis of a hybrid showed a twofold higher DNA content than the sake diploid parent, consistent with tetraploidy. By crossing strains of opposite mating type in all possible combinations, a number of hybrids were constructed. Hybrids formed in crosses between traditional sake strains and between a natural nonhaploid isolate and traditional sake strains displayed equivalent fermentation ability without any apparent defects and produced comparable or improved sake. Isolation of mating-competent auxotrophic mutants directly from industrial yeast strains allows crossbreeding to construct polyploids suitable for industrial use without dependence on sporulation.

Renal osteodystrophy is a major complication in hemodialysis patients. Measurement of serum peptide derived from the degradation of bone collagen could potentially provide an indirect estimate of bone resorption. The present study estimated the significance of the C-terminal telopeptide of type I collagen (beta-CTx) as a serum bone resorption marker in male hemodialysis patients. The mean age and hemodialysis duration of the 160 patients were 59.7 years (26-86 years) and 67.2 months (17-142 months), respectively. Bone mineral density (BMD) in the distal third of the radius was measured using dual-energy X-ray absorptiometry twice with a 2-year interval. A blood sample was collected immediately before the hemodialysis session at the time of the second BMD measurement. Other serum bone markers determined were bone-specific alkaline phosphatase (BAP) and intact and N-terminal midfragment (N-Mid) osteocalcin (OC) as bone-formation markers and serum pyridinoline (PYD) and deoxypyridinoline (DPD) as bone resorption markers. Serum beta-CTx correlated significantly in a positive manner with serum PYD, DPD, BAP, intact OC, and N-Mid OC. Serum beta-CTx, as well as PYD, DPD, BAP, intact OC, and N-Mid OC, correlated significantly with BMD in the distal third of the radius at the second measurement and with the rate of BMD reduction during the preceding 2 years. The highest quartile of serum beta-CTx was positively associated with rapid bone loss, defined as a change in the value for BMD in the distal third of the radius falling within the upper tertile of patients, in 55% of cases, and each quartile progress in serum beta-CTx increased the odds ratio of rapid bone loss by a factor of 1.73. Since the Youden index was twice as accurate for beta-CTx, BAP and N-Mid OC as for intact PTH, these bone-remodeling markers may be better risk markers of cortical bone loss than intact PTH. Inclusion in the highest quartile of PTH (above 288 pg/ml) predicted rapid bone loss with a sensitivity of only 26%. This means that the upper limit for serum PTH level recommended by K/DOQI may be too high, since 74% of cases with rapid bone loss showed serum PTH levels of below 288 pg/ml. In conclusion, serum measurement of beta-CTx may provide a new commercially viable and relevant serum assay to reflect cortical bone resorption in hemodialysis patients.